PHYSICIAN'S REPORT-CHILD CARE CENTERS

1 _____ _____ _____ _____ ____ _____ ___ _____ _____ _____ _____ _____ _____ STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING physician S report CHILD CARE CENTERS (CHILD S PRE-ADMISSION HEALTH EVALUATION) PART A PARENT S CONSENT (TO BE COMPLETED BY PARENT) (NAME OF CHILD) , born (BIRTH DATE) is being studied for readiness to enter (NAME OF CHILD CARE CENTER/SCHOOL) . This Child Care Center/School provides a program which extends from : to , days a week. Please provide a report on above-named child using the form below.

2 I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD S AUTHORIZED REPRESENTATIVE) (TODAY S DATE) PART B physician S report (TO BE COMPLETED BY physician ) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Speech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

3 VACCINE DATE EACH DOSE WAS GIVEN 1st 2nd 3rd 4th 5th POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ DT/Td (DIPHTHERIA, TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / HIB MENINGITIS (REQUIRED FOR CHILD CARE ONLY) (HAEMOPHILUS B)/ / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) Risk factors not present; TB skin test not required. Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present.

4 I have have not reviewed the above information with the parent/guardian. physician :Date of Physical Exam: Address:Date This Form Completed: Telephone: Signature physician physician s Assistant Nurse Practitioner LIC 701 (8/08) (Confidential) PAGE 1 OF 2 RISK FACTORS FOR TB IN CHILDREN: * Have a family member or contacts with a history of confirmed or suspected TB. * Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America). * Live in out-of-home placements. * Have, or are suspected to have, HIV infection. * Live with an adult with HIV seropositivity.

5 * Live with an adult who has been incarcerated in the last five years. * Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents in nursing homes. * Have abnormalities on chest X-ray suggestive of TB. * Have clinical evidence of TB. Consult with your local health department s TB control program on any aspects of TB prevention and treatment. LIC 701 (8/08) (Confidential) PAGE 2 of 2